Double Click This Header and Complete the Following on First Page Only. When Finished

DOUBLE CLICK THIS HEADER AND COMPLETE THE FOLLOWING ON FIRST PAGE ONLY. WHEN FINISHED, DOUBLE CLICK AGAIN AND RETURN TO THE MAIN DOCUMENT

CLUB NAME: CONTACT:

PROJECT NAME:

Club Name:

Project Chair:

Phone: Email:

The attached application is a Microsoft WORD form, which will expand as you write. We encourage you to be efficient in your wording, but to say enough that we and The Rotary Foundation can understand the focus and scope of your project.

It is important when planning your project that you clearly describe how you will demonstrate Rotarian involvement – a strict requirement of The Rotary Foundation. You may no longer simply write a check.

Finally, if your club has not done so yet, it must open a Future Vision Grants Account – a separate account which may ONLY be used for grant funds coming from The Rotary Foundation or District 5170. You must provide an original deposit slip for each application.

Note that in a departure with past practices, the final report and supporting documentation will be required by October 31, 2014.

When you have completed the attached form and obtained the signature of your current Club President, please complete the following checklist and submit with your application:

Please send your completed application and this form to the District 5170 Drop Box account

Instructions to submit to the Drop Box appear on the following page

Instructions to Upload your District Grant Application to Drop Box

Application must be in digital format

Go to in your browser

Click on “sign-in”

Sign in:e-mail address

Password rotary

Click on “District Grants”

Click on “2012-2013 Applications”

Click on your Area

Click on “web uploader” on the bottom right

Choose the file you want to upload (it must be saved on your computer first)

Highlight the file and click “open”

Click “Done”

Your file has been submitted to DropBox

If you are already a DropBox user you can request to share.

1. Club:

2. Project Name:

3. Describe the project, its location, objectives, the intended beneficiaries or community in need, and how they will benefit:

4. Start Date: Final Report for this grant is due October 31, 2014.*

New for 2013-2014:Your club will receive its new grant funds for 2013-2014

Projects when the final report(s) for its 2012-2013 grant is

Submitted and accepted by the District 5170Grants Committee.

* This is the firm date by which your club must file the final report for this project. By signing this form, the Club agrees that if it does not submit an approved report on this project by the Final Report Date given above, the Club will reimburse the Rotary District 5170 District Grant Account for the full amount of the grant. Failure to report and provide this reimbursement will mean that the Club will lose its Future Vision Qualification until such time as the amount is refunded.

5.The Rotary Foundation requires Rotarians to participate in non-financial ways. Describe anticipated participation by Rotarians in the project (i.e., Rotarian activities, number of Rotarians involved):

6.Club Project Contacts: Three Rotarians must be listed who will provide oversight and management of the project funds from start to completion of the final report:

Primary Contact: Rotary Position

Address:

Phone: FAX Email:

Second Contact: Rotary Position

Address:

Phone: FAX Email:

Third Contact:Rotary Position

Address:

Phone: FAX Email:

7.Host Partner Contacts(for International projects involving a District Grant)

Host Partner:Rotary Club of District:

Project Location:

Primary Contact: Rotary Position

Address:

Phone: FAX Email:

Second Contact: Rotary Position:

Address:

Phone: FAX Email:

Third Contact: Rotary Position

Address:

Phone: FAX Email:

Host Partner Club President:

(Print Name): Signature:

Phone: FAX Email:

8.Cooperating Organization: A cooperating organization is necessarily different from your project beneficiary. A cooperating organization is a third party organization that is operationally engaged in your project. . If the project involves a cooperating organization, provide the name of the organization below and attach a letter from that organization which specifically states its responsibilities and how Rotarians will interact with the organization in the project. By signing this application, the Club also endorses the organization as reputable and responsible.

Name of Cooperating Organization:

9.Publicity: How will the general public know this is a Rotary-sponsored project? Please provide details, e.g. Publicity and/or display of the Rotary wheel.

10. Budget: Please include a complete, detailed and itemized budget for the entire project below or attached. Supporting documentation utilized for the development of this budget may be requested.

11. Financing: How will the club finance the above budget?

Note: Total Financing MUST Equal the Total Budget

12.Authorization: All Rotary clubs/districts involved in this project are responsible to The Rotary Foundation for the conduct of the project and for reporting on it. The signatures on the application confirm that the sponsors understand and accept the responsibility. The signatures of the sponsors also affirm that all information in this application is true and accurate, to the best of their knowledge.

Club President: As President of the Rotary Club of

I hereby affirm that the club has voted to undertake this project as an activity of the club.

Club President Name:

Club President Email: Phone:

Club President Signature: Date:

Process: The District Grant Application will be reviewed by the District Grants Committee. The Primary Contact will be notified by email. Generally, the grant can be funded in a few weeks. Payment is subject to the Club being in good standing,and up to date in reporting of previous District Grants, Matching grants, Global Grants and RI/District financial obligations.Completed final report and supporting documentation is due no later than October 31, 2014

Submittal: Please upload this application and supporting documentation to the District 5170 Drop Box account, but if you have any questions, please contact:

Areas 1-3: Bob Dolci, phone: (408) 910-0759,

Areas 4-6:Georgie Hildebrand, phone (831) 461-7809,

Areas 7-9: Gerri Hussey, phone: (510) 471-0513,